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BUSINESS LIVE A Durban-based private hospital group is in a legal war with 13 medical aid schemes that it claims are refusing to pay R27-million it is owed for hundreds of “preauthorised” hospital visits. If this is not resolved, the patients could be sued for the money. City Hospital Pty Ltd, which owns City Hospital and Ascot Park Hospital, claims that administrator Medscheme is behind the payment ban because it raised “anomalies” in admission patterns at the two hospitals. It says Medscheme claims that certain directors of the group, who are doctors, are enriching themselves through admissions. The group claimed Medscheme refused to provide full details of the allegations. The two biggest debtors are Bonitas, which owes R14.5-million, and Polmed, which owes just under R10-million. The hospital group says it is being financially crippled by the non-payment and wants a court to direct that the registrar and the Council for Medical Schemes (CMS) undertake an urgent inquiry into the matter. Undesirable business practice It wants CMS to declare the conduct of medical aid schemes as an “undesirable business practice” and to probe who at Medscheme motivated for the medical aids to withhold payment and “to what extent is the type of behaviour is prevalent against others and who they are”. But CMS CEO Dr Sipho Kabane, in an affidavit filed with the Durban High Court, said that the complaints process is governed by legislation. He said it is inappropriate for the applicant to seek that this court direct how an investigation should be conducted. Paul Midlane, GM of healthcare forensics for Medscheme, said an audit had revealed that doctors with the highest admission rates were also shareholders in the group. He said that while it is not unlawful, admitting doctors have an ethical duty to notify patients of this potential conflict of interest. Admitted without screening Midlane said the majority of patients were admitted directly into the hospital without screening, adding that it was clear that doctors were admitting the vast majority of patients and then only consulting for the first time. Midlane said pre-authorisations were issued in good faith and were not a guarantee of payment. He said that in the past two years, Medscheme had paid the hospitals R323-million and he believed a substantial portion of that could have been avoided if it were not for unnecessary admissions. In his affidavit, the group’s GM Vishnu Rampartab, pinned the blame for the non-payment on Medscheme manager Mcdonald Marabo who he said “lacks objectivity” and “has an agenda”. In disputing claims that doctors are enriching themselves, he said the sole shareholder of the group is Joint Medical Holdings “which in turn has two corporate shareholders whose shareholding exceeds 490 different shareholders of which the applicant’s directors constitute a minority”. Payments on hold Rampartab said he was contacted by Marabo in June 2018 who said he had concerns about admission patterns. He did not define them but said all payments would be put on hold. The initial complaint was against Ascot Park, but in November the allegations were repeated against doctors at City Hospital. Rampartab said that Marabo had met one doctor privately “and had threatened to withhold payments to him unless he abandoned significant amounts of his claim”. The group sought the opinion of Deborah Pearmain, an expert in liability of medical schemes, who confirmed that “withholding payment on the grounds of alleged unethical conduct by medical practitioners who work at hospitals is unlawful”. Attorney Aneesa Mahomed, for Bonitas, said the scheme, upon the furnishing of the claims by City Hospital, would analyse them “and then take a view regarding their validity”. Mahomed said while Medscheme has a duty to check for possible fraud, it is subservient to the medical aid schemes and Bonitas can act independently of it. She said it was possible that should payments not be made, the hospital could make claims against patients “but they will have to prove that the claims are valid”. Polmed principal officer Neo Khauoe said they were opposing the application. He said the scheme has a duty to protect interests of members, including not paying for potential overservicing or overcharging.
Created at 2019/03/11 09:38 AM by Mediclinic
Last modified at 2019/03/11 09:38 AM by Mediclinic